CMS Imposes First-Ever Home Health Moratorium

By Jason Oliva | July 29, 2013

In its latest efforts to combat fraudulent billing behavior, the Centers for Medicare & Medicaid Services (CMS) has imposed the first Affordable Care Act (ACA) moratorium to bar the enrollment of new home health providers in the federal program.

“The goal of the temporary moratoria is to fight fraud and safeguard taxpayer dollars, while enduring patient access to care,” CMS wrote in a release. “Authority to impose such moratoria was included in the Affordable Care Act, and CMS is exercising this authority for the first time.”

Under the moratoria, existing providers and suppliers can continue to deliver and bill for services, however, no new provider or supplier applications will be approved for CMS’ Medicare, Medicaid and Children’s Health Insurance Program (CHIP).

The temporary moratoria doesn’t extend nationally, zeroing in instead on newly-enrolling home health agencies in the Miami and Chicago metro areas, as well as ground ambulance suppliers in the Houston metro area—three areas noted by CMS as “hot spots” for fraud.

Working with the Department of Health and Human Services Office of Inspector General and the Department of Justice, CMS determined that fraud trends warranted a moratorium on home health providers and ambulance suppliers in these three geographic areas.

The agency also reviewed key factors that it believes are indicators of potential fraud risk, including a disproportionate number of providers and suppliers relative to beneficiaries, a rapid increase in enrollment applications from providers and suppliers, and levels of “extremely” high utilization.

“CMS is using all available tools, including these moratoria, to combat fraud, waste and abuse in these vital health care programs,” said CMS Administrator Marilyn Tavenner. “While maintaining patients’ access to care, we are putting would-be fraudsters on notice that we will find and stop them before they can attempt to bill Medicare, Medicaid and CHIP.”

The affected counties in each of the three targeted metro areas are Miami-Dade and Monroe in Florida; Cook, Dupage, Kane, Lake, McHenry and Will in Illinois; and Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery and Waller in Texas.

On a state level, CMS also worked with Florida, Illinois and Texas to evaluate patient access to care and is working with its partners to monitor the impact of the moratoria that is set to take effect Tuesday, July 30.

CMS may lift the moratoria earlier or extend it another six months by issuing another notice in the Federal Register, according to a release from the agency.

The newly imposed moratoria is the latest move from the federal agency in its efforts to combat aberrant billing behaviors in the home health industry–efforts that have been applauded by industry trade groups such as the National Association for Home Care & Hospice (NAHC).

“We fully support the action taken by CMS,” stated Val J. Halamandaris, president of NAHC. “NAHC has long supported program integrity measures such as this and strongly recommended that Congress give CMS the authority to issue a moratorium as part of the Affordable Care Act. We look forward to continue working with CMS as it considers other areas of the country where a moratorium may be needed.”

Since March 2011, CMS has revoked 14,663 providers’ and suppliers’ ability to bill in the Medicare program for reasons including, but not limed to, felony convictions and noncompliance with federal regulations.